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APPLICATION FOR PERMIT * c SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he,aby made to the San Joaquin Local Health District for a permit to Construct and!or instait the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 5419 for sewage or No. 1862 for vwil/purr¢and the Rules and Regulations of the San Joaquin Local Health District. Job Address `s City_ _ Lot Size _ _ PM Owner's Name - Address l _ F'honeU��Z-�//O %��,� Contractor. /��5 Address �9 r j �oy��,¢9s�yz L'- -7 TYPE OF WELL/PUMP: NEW WELL ❑ License No. Phones��.�� -- WELL REPLACEMENT i:J DESTRUCTION La PUMP INSTALLATION I SYSTEM REPAIR p DISTANCE TO NEAREST; SEPTIC TANK orHe� SEWER LINES � DISPOSAL FLD„— PROP. LINE FOUNDATION ,__ AGRICULTURE WELL ,. OTHER WELL. _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS— �1rS/SUMPS ❑ Industrial aLOpen Bottom U Manteca ”' Die. of Well Excavation -/ � Di, of Well Casing /r.UyF I`7 Domestic/Private L7 Gravel Pack f-I Trac Tracy Type of Crrsing Specifications f'i Public l:1 Other I I Delta Depth of Grout Seai / 7� I I Irrlpation ' ' _ A Type of Grout . Apprpx, Depth f I Eestorn Such— Semi installed by fs �.vvi�•wry�C ��! Repair Work Done U Type of Pump H.P. Well Destruction ❑ Well Diameter _ ,e.c•,( State Work Done So�1S.�.ry scaling Material flop 50'1 Depth ` ?� ' Filler Material faelow 5411 TYPE OF SEPTIC WORK: NEW INSTALLATION E I i1LE'AIR:ADDittpN i I DESTRUCTION i I INo septic system permitted if public sower is Installation will serve: ResidenceCommercial_ Other available within 200 feet.) _ _ Number of living units: Number of bedroom$ Character Of soil to a depth of 3 feet: SEPTIC TANK © Type/Mfg Water table depth PKG. TREATMENT PLT.❑ Capacfty— No. Compartments Distance to nearest: Well Method of Disposal Foundation. Property Line LEACHING LINE I-1 No. 8 Length of lines _- FILTER BED I0 Distance to nearest: Well Total bn Property _ _.. Foundation Property Line---- SEEPAGE SEEPAGE PITS I I Depth _. Size SUMPS LI Distance to nearest: Wel — Number L-1 DISPOSAL PONDS Foundation—. Property Line I heraby certify that l have orepared this application and that the work will f rules and regulations of the San J ?e done in accordance with San Joaquin courtly ordinaRCCs. state leti,rs, and Oaquin Local Health that t Home owner Or licensed agent's signature certifies the following; "I certify that in the performance Of the work for which this employ any person in such manner as to become subject to workman's Compensation laws of California." Marti) is issued, f signal not certifies the following: "1 certify that in the parformaRce of tf,s work for which b ` Contractor's hiring or sub CpniraCtin tion burs of California.- The ch this permit is iswed, I shall employ persons sub" 9 signatureense- laci t0 wOrkrnaR's t-0►ntianse- The applicant muusst cal fl 0 alt required inspections. Complete drawl Signed /��'/J�F� /1/f'fI/�7� r'a on reverse side. f ; �. Title: i7 Date: FOR 7MEfYT USE ONLY Application Accapted by _. Dat./A Pit or Grout Inspection by Date Final Inspection b Z�F'(f Additional Comments: Date e ---� © Stk 466.6787 ❑ Lodi 369-3621 t"7. Manteca e23.7104 ❑ Tracy 835.13385 Applicant • Return ail Copies to: Environmental Health Permit/Services 160, E. Hazelton Ave.. P.O. Box 2009, Stk., CA 9$201 FEE AMOUNT DUE A Cx o (Nip MOUNT REMIT ED av CASH ARCEIVED bATF PERMIT'No. EM 13.2 (REV.,i n�� j